Welcome to our office: New Patient Paperwork: Co-Pays and Deductibles: Insurance information: Prescription Refills: Medical Records Request:

Transcription

1 9330 Poppy Dr. Suite 400 Dallas, TX Phone: (469) Fax: (972) Welcome to our office: Thank you for choosing our practice and allowing us to take part in your medical care. It is our desire to make your visit with us as pleasant as possible. With your help as discussed below, we will be better able to serve you and meet your needs. New Patient Paperwork: Please bring your completed new patient paperwork with you to your appointment with us. This will allow us to serve you more efficiently by entering your information into the computer in a timelier manner. Co-Pays and Deductibles: Most of the insurance companies require us to receive payment of your co-pay at check in; therefore we will ask you when you check in for your co-pay. You are responsible for your deductible at the time of service. Insurance information: It is of the utmost importance your insurance information be current. You will be given and asked to initial a printout of the current information that we have at every visit. If you have changes in your current information, we will ask you to fill out new paperwork to document your new information. If your insurance has changed and you have not received your ID card, you will need to provide us with the name of the insurance, the subscribers name, social security number and date of birth, the policy ID, the group number, the claims mailing address, and a phone number to contact the insurance company. Without this information, we will not be able to file your claim properly and you will be asked to pay for the services in full or reschedule your appointment. Prescription Refills: Please make a conscious effort to be aware of your medication supply. Call your pharmacy a few days prior to needing the medication refilled to give enough time for the refill process to take place. Certain medications may require you to see the physician before being refilled; please call a week before needing the refilled medication to allow us time to make an appointment for you. We may not be able to authorize refills for patients we have not seen in our office in excess of one year. Please have your pharmacy phone number available when calling regarding medication. This office does NOT handle refills after hours. Medical Records Request: Due to the HIPAA regulations, we need a signed release from the patient to release records. We require at least 48-hour notice to process your request. There may be a charge for records not going to another medical entity.

2 Patient Portal Manage Your Health Your Way! is proud to offer you access to our Patient Portal which simplifies communication with your physician. The Portal is a secure, confidential and easy to use website that gives patients and their families 24 hour access to their medical records. You can access the East Lake Medical Group Patient Portal from the comforts of your home or office or anywhere else you choose to login. You can use the the East Lake Medical Group Patient Portal anytime to: Request, Book and/or Cancel appointments Request prescription refills View statements and pay online Review test results sent from your provider Obtain educational information Send and receive secure messages to and from your provider Maintain account information including user name, password, access privileges, and address Sign up with multiple practices in the same Practice Network Note: Practices in the Network can customize their Patient Portal to meet their requirements. Therefore, some of the features listed above may not be available from your Patient Portal account. Through the the East Lake Medical Group Patient Portal you will receive notices to your personal account when there is important information awaiting you in your Patient Portal account. Your name and will be treated with the same care and privacy given to your medical records. Sign up is easy for the East Lake Medical Group Patient Portal! Our office staff is eager to help you obtain a token that will allow you to access your online account. Contact us to get started!

3 ADULT PATIENT INFORMATION WE STRIVE TO KEEP ALL INFORMATION IN CONFIDENCE AND WILL NOT RELEASE WITHOUT SIGNED CONSENT. It may be sent to consultants, if referred. NAME: DATE: / / BIRTH DATE: / / AGE: GENDER: M / F PREFERRED PHARMACY: NAME PREVIOUS PHYSICIAN: NAME PH. NUMBER PH. NUMBER MEDICAL CONDITION(S) / HOSPITALIZATIONS: (Example: Diabetes, High Blood Pressure, Asthma...) ALLERGIES: (Medications, Food, Insects) SURGERIES: (Example: Tonsillectomy, Gallbladder, Hernia Repair...) TYPE OF SURGERY YEAR MEDICATIONS: (Please include vitamins and herbals) DRUG DOSE HOW MANY TIMES PER DAY? Ex: Advil 200mg 3 times per day LAST MENSTRUAL CYCLE: / / LAST PAP SMEAR: HAVE YOU EVER HAD AN ABNORMAL PAP SMEAR? Y / N LAST MAMMOGRAM (if over age 40): LAST BONE DENSITY TEST (if after menopause): LAST TESTICULAR EXAM: LAST PROSTATE EXAM (if over age 50): A-02.form.ITMC.Adult.Patient.Information.doc Rev. (01/08)

4 ADULT PATIENT INFORMATION NAME: DATE: / / LAST FIRST M.I. LAST COLONOSCOPY (if over age 50): LAST TETANUS SHOT: LAST FLU SHOT: LAST PNEUMONIA: RECEIVED ALL 3 DOSES OF HEPATITIS B VACCINE? Y / N HAD CHICKEN POX AS A CHILD OR THE LIVARICELLA VACCINE? Y / N (or approximate if known): / / OCCUPATION(S): MARITAL STATUS: Single Married Divorced Separated Widowed HOW WOULD YOU CLASSIFY YOUR NUTRITION? Excellent Good Fair Poor EXERCISE REGULARLY? Y / N TYPE: TIMES PER WEEK: HOW LONG? (min) TOBACCO USE CURRENTLY? Y / N IF YES, # PACKS PER DAY FOR HOW MANY YEARS? TOBACCO USE IN THE PAST? Y / N IF YES, WHEN DID YOU QUIT? HOW MANY YEARS DID YOU SMOKE? ALCOHOL USE? Y / N ALCOHOL USE IN THE PAST? Y / N NUMBER OF DRINKS PER DAY? TYPE OF ALCOHOL? (Ex: beer, vodka, cocktails?) DRUG USE CURRENTLY? Y / N DRUG USE IN THE PAST? Y / N TYPE OF DRUGS? (Ex: marijuana, cocaine, heroin?) HAVE YOU EVER INJECTED YOURSELF WITH DRUGS? Y / N CAFFEINE USE? Y / N HOW MANY CUPS OF COFFEE PER DAY? NUMBER OF SODAS PER DAY? DO YOU WEAR YOUR SEATBELT? Y / N DO YOU OWN A FIREARM? Y / N FAMILY HISTORY: (Very Important: Please list medical conditions that run in your family. For example: heart attack, stroke, high blood pressure, high cholesterol, cancer, depression, etc... And specify whether deceased or living.) CONDITION(S) LIVING? FATHER: Y / N MOTHER: Y / N BROTHER(S) Y / N SISTER(S): Y / N GRANDPARENTS: MATERNAL: Y / N PATERNAL: Y / N A-02.form.ITMC.Adult.Patient.Information.doc Rev. (01/08)

5 EAST LAKE MEDICAL GROUP/ ARLENE BETANCOURT, MD REGISTRATION FORM (Please Print) Today s date: PCP: PATIENT INFORMATION Patient s last name: First: Middle: Mr. Mrs. Miss Ms. Marital status (circle one) Single / Mar / Div / Sep / Wid Is this your legal name? If not, what is your legal name? (Former name): Birth date: Age: Sex: Yes No / / M F Street address: Social Security no.: Home phone no.: ( ) P.O. box: City: State: ZIP Code: Occupation: Employer: Employer phone no.: ( ) Chose clinic because/referred to clinic by (please check one box): Dr. Insurance Plan Hospital Family Friend Close to home/work Yellow Pages Other Other family members seen here: INSURANCE INFORMATION (Please give your insurance card to the receptionist.) Person responsible for bill: Birth date: Address (if different): Home phone no.: / / ( ) Is this person a patient here? Yes No Occupation: Employer: Employer address: Employer phone no.: ( ) Is this patient covered by insurance? Yes No Please indicate primary insurance Subscriber s name: Subscriber s S.S. no.: Birth date: Group no.: Policy no.: Co-payment: / / $ Patient s relationship to subscriber: Self Spouse Child Other Name of secondary insurance (if applicable): Subscriber s name: Group no.: Policy no.: Patient s relationship to subscriber: Self Spouse Child Other IN CASE OF EMERGENCY Name of local friend or relative (not living at same address): Relationship to patient: Home phone no.: Work phone no.: ( ) ( ) The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize East Lake Medical Group/ Arlene Betancourt, MD or insurance company to release any information required to process my claims. Patient/Guardian signature

6 Important PATIENT INFORMATION NOTICE Physician office compliance with RED FLAG RULE The Federal Trade Commission (FTC), in conjunction with other agencies, published the Red Flag Rules defining what a creditor and financial institution must do to implement am Identity Theft Program. The Red Flag Rules require those covered, including medical practices, to identify at-risk accounts and to define, detect, and respond to Red Flags in order to prevent or mitigate identity theft. Medical Identity theft happens when a person seeks health care using someone else s name or insurance information. We are committed to protecting your identity and have developed a compliance policy that will help us protect your vital personal information. Beginning October 1, 2010, our staff will be asking patients and/or guardians to provide the following at each appointment: Photo ID ( Driver License, Passport, Employment picture ID ) Current Insurance Card Verification of patient demographics, including phone number and address. Please Note: No one, including minors, will be permitted to use a Medical-Flex Card, major credit card, r make a payment by check if the patient name does not match the form of payment used UNLESS we have written permission from the payer. We have a form available for the person named on the card or check to complete, sign and return to our office. The form provides permission for the specifically names patient to use that payment type for the required payments needed. This form will only need to be completed once. Please remember that this is being instituted for your protection. East Lake Medical Group is committed to protect our patients through the highest-level quality of care and unparalleled services. Thank you for your assistance in helping us comply with our Identity Theft Program. If you would like a complete copy of the Red Flag Rules, please ask the receptionist and she will be happy to provide you with a copy. Signature Line

7 9330 Poppy Dr. Suite 400 Dallas, TX Office: (469) Fax: (972) Acknowledgement of Receipts Notice of Privacy Practices I have been provided with a Notice of Privacy that provides me a more complete description of the uses and disclosures of certain health information. I understand East Lake Medical Group, reserves the right to change their Notice of Privacy Practice and prior to implementation will provide an updated Notice of Privacy Practice and will provide and updated copy in the physician s office. I may request a copy of the updated Notice of Privacy Practices by calling my physician s office or requesting a copy in person at my appointment. Patient s Printed Name Patient/Legal Representative Signature of Birth Relationship to Patient Witness I wish to be contacted in the following manner: Home Telephone: (choose one) Ok to leave a message with detailed information Leave a message with call-back number only Work Phone: (choose one) Ok to leave a message with detailed information Leave a message with call-back number only The following names are of people I would like to be involved in or have access to my protected health information on a routine basis. I give permission for East Lake Medical Group, to share my protected health information with anyone listed below: Name Name Name Relationship Relationship Relationship

8 9330 Poppy Dr. Suite 400 Dallas, TX Office: (469) Fax: (972) Financial Policy Thank you for choosing East Lake Medical Group, as your health care provider. We are committed to providing excellent healthcare services to you, our patients. As a part of our professional relationship, it is important that you have an understanding of our financial policy. All Patients must read and sign this form prior to receiving services. It is your responsibility to provide us with your most current insurance information. If you fail to provide accurate insurance in a timely manner, your insurance company may deny the claim. If the claim is denied, you will be financially responsible for the services rendered. We must emphasize that, as a medical provider, our relationship is with you, the patient, and not your insurance company. Your insurance is a contract between you, your insurance company and possibly your employer. It is your responsibility to know and understand the level of services covered by your insurance. If you have Medicaid coverage of any kind, you must notify us prior to your visit. This is part of your agreement with Medicaid, and failure to notify us of Medicaid coverage will result in full financial responsibility for services rendered. We may accept assignment of insurance after verification of your coverage. Please be aware that your insurance company may not cover some or perhaps all of the services provided in full. You are financially responsible for services not covered by your insurance company. Before receiving services, you must verify that we are participating providers for your insurance company. In the event we are not participating providers with your insurance company, we will file the initial claim as a courtesy. Payment, however, is due in full at the time of service. We charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company s arbitrary determination of usual and customary rates. Copayments, coinsurance, and/or deductibles are due at the time of service. We will estimate the amount you owe based on information we receive from your insurance company. However, you are responsible for paying the full amount determined by your insurance company once they have paid your claim-regardless of our estimation. It is your responsibility to provide us with your most current billing information. You must provide your most current billing address, all available telephone numbers and any important contact information. If your address or contact information changes, it is your responsibility to contact us with the update information. We will send a statement (to the billing address you provide) notifying you of any balance you may owe. If you have any questions or dispute a validity of this balance, it is your responsibility to contact our business office within 30 days after receipt of the initial statement. You can call (972) Payment in full is due upon receipt of the statement. Patient balances not paid in full within 30 days of the statement issue date are deemed past due. Past due accounts may be subject to a $5.00 monthly late fee and may be referred to a professional collection agency and/or attorney for further collection activity. You will be responsible to pay all costs incurred, including attorney s fees and court costs if applicable. If you are not able to pay the balance due in full, you must contact our billing office to discuss a payment schedule. Any late fees already incurred on past due balances will be included in any mutually agreed upon arrangements. If you fail to make payments as agreed upon, your account may be sent to a professional collection agency and/or attorney. You will be responsible for all collection costs incurred, including attorney fees and court costs if applicable. If your account is assigned to a professional collection agency, you will be notified by certified mail that you will no longer be able to receive services from any of the physicians. Failure to accept this certified letter (and/or pick it up at the post office) serves as notice of termination of services. In the event you submit payment by check and the bank returns the check unpaid for any reason, we will add $25.00 to your original balance. In addition, we may seek all additional legal remedies provided to us under Texas law. We may charge you a No Show fee if you fail to cancel or reschedule your appointment at least 24 hours prior to your appointment date. Failure to keep your account balance current may require us to cancel or reschedule your appointment. Full payment is due at the time of service. We accept cash, checks, and credit cards. I have read and understand the Financial Policy. Signature of Responsible Party Patient Name: Patient of Birth

9 9330 Poppy Dr. Suite 400 Dallas, TX Office: (469) Fax: (972) Authorization to Release Medical Information I,, hereby authorize (Name of patient or legal representative) (Name of person/entity who should release records) (Address of person who should release records) to release the following information by mail, fax, electronically or orally to: Eastlake Medical Group 9330 Poppy Dr. Suite 400 Dallas, TX Office: (469) Fax: (972) From the health records of: (Name of person whose record will be disclosed) (Social Security Number) For the purpose of: All Records: Statements of charges or payments Progress Notes Records of all visits Discharge Summary AIDS or HIV information Consultation Reports History and Physical Examination Hepatitis Information Photographs, videotapes, digital, or other images Mental health and/or alcohol and drug abuse treatment Copies of records or reports provided to the above names (i.e. hospital, lab, clinic, etc.) Record of visit for a specific date(s) This authorization is given freely with the understanding that: 1. Any and all records, whether, oral, or in electronic format, are confidential and cannot be disclosed without my prior written authorization, except as otherwise provided by law. 2. A photocopy or fax of this authorization is as valid as the original. 3. I may revoke this authorization at any time in writing, except where information has already been released. 4. Eastlake Medical Group, its employees, officers, and physicians are hereby released from any legal responsibility or liability for receipt of the above information to the extent indicated and authorized herein. 5. Information used or disclosed pursuant to the authorization may be subject to disclosure by the recipient and may no longer be protected by this rule. 6. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on obtaining this authorization. Patient s Printed Name Patient/Legal Representative Signature Relationship to Patient Witness of Birth Expiration of Authorization